HomeMy WebLinkAboutCLE201700124 Application 2017-06-05Application for Zoning Clearance
10
OFFICE LNU ONLN
PLEASE REVIEW ALL 3 SHEFTS
('Iicck#
Receipt # r) C '4 Staff:
---1
PARCEL INFORMATION
Tax Map and Parcel:
Parcel Owner: —
Parcel Address: %zip-zzq h
(include suite r floor)
PRIMARY CONTACT
Who should we call/write concerning this project? C11 6 14--
.Xddress : SStv zip 1 �h, � cil, tatva st,
Office Phone: Ccl I H Fax 4 Email Cc
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name Net+ business
Business Namerrype: +lei
Previous Business on this site
Describe the proposed business including use, number of employees, nuipber of shifts. available parking spaces,n her of
vehicle,S, sy am �additional tnfirmation that you c pro ide: b1fiUl S4 474 z6J6 leiTAI
-,�Abey\ cc VI —a A fa2 IR a
—PP-04vac-
- )4 r\
'Oelk AtUjVtX---
*This ("Icarance will only he Va6d 6n the pakel liar "hich it is apta-mcd. It'Nou change. intensity or inure the use to it new location. a new /oning,
Clearance will he required.
I hereby i:crtify that I own or ha%e the owner's pertni,,im) to tjA- the space indicutcd on this application- I also ccrtifj that the intimnation pnv% idcd
is true and accurate to the best.ol'1113, knowledge. I hate read the conditions ul'approN al. and I understand them. and that I will abide by them.
Signature printed
APPROVAL INFORMATION
,tPJ Approved as proposed j Approved with conditions Dented
Backflow prevention device andiorcurt-crit test data needed for this site. Contact ACSA. 977-4i11, xl 17.
No physical site inspection has been done lbr this clearance. Thererore, it is not a detenninalion ofcompliance with the existing
site plan.
[ ] This site complies with the site plan as of this date.
Notes:
Building official 1117
Date
Zoning official Date
V
Other official 7 Date
17
L,01.11711Y 01 Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 266-5832 Fax: (434) 972-4126
Revised 7; 1 /2011 Page 2 of'3
Intake to complete the following:
Y A�q
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y
Wi there be food preparation?
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on private well fpu ter?
If private well, provide He rtment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that ap�uLs=
Is parcel on septic or blic s
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use: �_� oy
Y/N %
Permitted as: ,> SA / e .�
Under Section: AA4
Supplementary regulations section:
Parking formula:
Required spaces:
Y
Items o be verified i„ the field:
Inspector Date:
Notes:
Violations:
Y/1W
If so, List:
P offers:
0/N
If so, List:
P's:
4 / N
If so, List:
d2-57
Varia e:
Y/6)
If so, List:
Clearances:
SDP's
U 2 —/�7
2
I
Revised 7/1/2011 Page 3 of 3
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning applications (Home Occupation, Zoning Clearance, Zoning
Administrator Determinations or Appeals, Sign Permits, Building Permits) if the application is not the
owner.
I certify that notice of the application,
was provided to
[County application name and number]
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
Hand delivering a copy of the application to
the owner of record of Tax Map
by delivering a copy of the application in the
[Name of the record owner if the record owner is a
person; if the owner of record is an entity, identify the recipient of the record and the recipient's
title or office for that entity]
m
Date
Mailing a copy of the application to Cbtll S W ,►If41Y�15 JA-• �-�'i.f,�lUn�� �Sl n 1
[Name of the record owner if the record owner is a person;
if the owner of record is an entity, identify the recipient of the record and the recipient's title or
office for that entity]
on _ to the following address:
Date
[address; written notice mailed to the owner at the last knoNknJaddress of the owner as shown on
the current real estate tax assessment books or current real estate tax assessment records satisfies
this requirement].
a&L
Signature of Applicant
Ctin,;s c001L
Print Applicant Name
Date
AC IR,V CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDD VYYV)
12/ 16/2016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsements .
PRODUCER
Britton Gallagher
One Cleveland Center, Floor 30
1375 East 9th Street
CONTACT
NAME:
_
tPlyH o. Ext):216-658-7100 a/c No):216-658-7101
E-MAIL
ADDRESS:
Cleveland OH 44114
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURER A:Maxum Irld mni mDainy
74
INSURED 8086
INSURER 8.Ever IndemnityInsurance Co0
51
INSURER C :
Keystone Novelties Distributors LLC
INSURER D :
201 Seymour Street
Lancaster PA 17603
INSURER E :
INSURER F :
CnVFRAGES CERTIFICATE NUMBER: 6QRnAnA4A REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY.CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
DD
INSR
R
WVD
POLICY NUMBER
POLICY EFF
(MMIDDNYYYI.
POLICY EXP
JMMIDDIYYYYILIMITS
B
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE K OCCUR
S18ML00041-161
12/31/2016
I
12/31/2017
EACH OCCURRENCE
$1,000,000
DAMA E T REN D
PREMISES Ea occurrence
$500,000
MED EXP (Any one person)
$ _
PERSONAL & ADV INJURY
$1,000,000
GENERAL AGGREGATE
$2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PRO X LOC
PRODUCTS - COMP/OP AGG
$2,000,000
_
$
AUTOMOBILE LIABILITY
ANY AUTO
ALLOWNED SCHEDULED
AUTOS AUTOS
NON-OWNED
HIRED AUTOS AUTOS
Ea accident
$
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
-
PROPERTY DAMAGE
Per accident)
----—
$
A
X
UMBRELLA LIAB
EXCESS LIAB
N
OCCUR
CLAIMS -MADE
EXC6018961
12/31/2016
12/31/2017
EACH OCCURRENCE
$4,000,000
AGGREGATE
$4,000,000
DED RETENTION $
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y/ N
ANY PROPRIETOR/PARTNER/EXECUTIVE ❑
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
N / A
WC STATU- O R
T Y LIMI
_
E.L. EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYEE
$
E.L. DISEASE - POLICY LIMIT
$
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Additional Insured extension of coverage is provided by above referenced General Liability policy where
required by written agreement.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE -
U 1988-2010 AGUKU GUKVUKA I IUN. Ali rlgnis reserves.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
r
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GO
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